The Primary Care Practitioner’s Role in the Prevention and Management of Alcohol Problems

Medical practice in the United States has focused on diagnosing and treating alcohol abuse and dependence. A preventative approach to alcohol problems, however, requires that primary care practioners also identify patients whose patterns of alcohol consumption place them at risk for alcohol-related problems.


Alcohol Abuse and Dependence
three to four times more likely than wom en to develop drinking problems (Bradley article,see p. 99) to treatment specialists These disorders are common in primary 1992). In men, heavy drinking often to prevent additional alcohol problems care settings. Their prevalence ranges begins in the teenage years, with the risk and minimize disability (Barnes et al. from 11 to 20 percent in general medical of alcoholrelated problems reaching a 1987). This type of intervention can be clinics (Bradley 1992), 8 to 16 percent in peak in the early twenties (Bradley 1992). thought of as tertiary prevention (see the family practice clinics (Leckman et al. Women tend to develop drinking prob sidebar, p. 100). Recent research, how 1984;Schorling et al. 1994), and 12 to 16 lems at a slightly older age than men, but ever, has demonstrated that counseling medical complications tend to occur at patients with hazardous drinking patterns KATHARINE A. BRADLEY, M.D., M.P.H., is similar ages in men and women (Blume or mild alcoholrelated problems that do an acting instructor in the Department of 1986). Youth who begin to use alcohol not meet diagnostic criteria for alcohol Medicine, University of Washington, and before age 16 (Smith 1993), or those with disorders, or secondary prevention, also is a senior fellow in the Section of General antisocial behavior (Vaillant 1983), are effective in primary care settings (Bien et Internal Medicine and Health Services more likely to develop alcohol problems. al. 1993). Although the efficacy of advis Research and Development, Seattle A genetic or cultural predisposition ing all patients about safe drinking prac Veterans Affairs Medical Center, Seattle, clearly places some people at higher risk tices, or primary prevention, is not known, Washington. than others (Schuckit 1985;Vaillant 1983).
Spectrum of problems related to alcohol use. Men with two or more alcoholic relatives are about three times more likely to become alcohol dependent than those without (Vaillant 1983). Northern Europeans (Vaillant 1983) and some Native American groups (Institute of Medicine [IOM] 1990) also are at increased risk of developing drinking problems.

Hazardous Drinking
Available evidence suggests that hazardous drinking is relatively common among primary care patients. Saunders and col leagues (1993a) reported that 19 percent of patients who drank alcohol consumed potentially hazardous amounts. Russell and Bigler (1979) found 19 percent of women in a gynecology practice to be heavy drinkers. Although the prevalence of haz ardous drinking among pediatric primary care patients is not known, onethird of high school seniors engage in binge drink ing at least every 2 weeks (Smith 1993).
Epidemiologic studies have identified several patterns of drinking that place people at increased risk for alcohol prob lems. Chronic heavy alcohol consumption can increase risk for cardiovascular dis ease, cirrhosis, and cancer (Bradley et al. 1993; National Institute on Alcohol Abuse and Alcoholism [NIAAA] 1993a). Consuming as few as two drinks daily has been associated with elevated blood pressure (Friedman 1990) and more than five drinks daily with increased mortality (Klatsky et al. 1992).
Episodic heavy drinking also is linked with adverse consequences, probably as a result of intoxication. Consuming more than four drinks per occasion has been associated with risktaking behaviors (e.g., unplanned sexual activity and driving after drinking) and physical fights and blackouts in young adults (college students under 21 years old) (Wechsler and Isaac 1992).
Risks related to hazardous drinking often depend on the setting and the amount of alcohol consumed. Drinking when participating in water sports or before driving can be especially hazardous (How land et al. 1990;Simel and Feussner 1990). For women, drinking more than 13 drinks a week at the time of conception is associ ated with abnormal fetal growth and devel opment and fetal loss; more than 42 drinks a week significantly increases the risk of fetal alcohol syndrome . For 14 to 16yearolds, any drinking is associated with increased cigarette smok ing and alcohol abuse later in life, and binge drinking is linked with property damage, poor academic performance, and violent behavior (Smith 1993). For par ents, drinking is associated with acciden tal injury and child abuse (Macdonald and Blume 1986).

SCREENING FOR PROBLEM AND HAZARDOUS DRINKING
Because many alcoholdependent patients have no identifiable risk factors for alco hol problems, all primary care patients should be screened during the initial appointment and periodically thereafter. When the patient is a dependent child or is elderly, the practitioner should consider screening parents and caregivers as well (Macdonald and Blume 1986).

Alcohol Abuse and Dependence
Identifying patients with alcohol abuse and dependence is complicated by the possibility that some patients will not recognize or admit that they have an alcohol problem. Consequently, several screening questionnaires have been devel oped to aid in identification (Bradley 1992), because they are a more sensitive means for detecting alcohol disorders than physical examination findings and labora tory tests (Skinner et al. 1986). For exam ple, the CAGE (see Nilssen and Cone for this and other screening tests, pp. 136-139), which contains four questions, is probably the easiest for clinicians to remember (Ewing 1984).

Hazardous Drinking and Mild Alcohol Problems
Although the CAGE is a good screening test for alcohol problems, it is an insensi tive one for hazardous drinking (Wallace et al. 1987;Waterson and MurrayLyon 1988). If the CAGE is used to identify hazardous drinking, it should be followed by questions about alcohol consumption or tolerance or both (Steinweg and Worth 1993). Although there is no consensus on a threshold for hazardous alcohol con sumption, more than two drinks daily or more than three drinks per occasion can be considered potentially hazardous (Bradley et al. 1993).
Several newer screening question naires specifically designed to identify hazardous drinking as well as alcohol problems appear promising. The Alcohol Use Disorders Identification Test (AUDIT) is a 10question test developed by the World Health Organization (Saunders et al. 1993b). The fivequestion TWEAK, originally developed to screen pregnant women, recently was found to be effec tive for other primary care patients (Chan et al. 1993). Although two versions of the TWEAK have been described, one ap pears to function better in clinical pa tients. Numerous instruments also have been developed specifically to identify hazardous and problem drinking by ado lescents (NIAAA 1993b).
A laboratory test that measures the level of the liver enzyme gammaglutamyl transferase (GGT) in the serum also will identify many patients with hazardous drinking. This GGT test, however, is generally less sensitive than screening questionnaires (Kristenson et al. 1983).

FURTHER ASSESSMENT OF PATIENTS WHO SCREEN POSITIVE
Adults who screen positive for problem or hazardous drinking require further assess ment. In children, any drinking should trigger further assessment. An assessment interview can be done by a primary care nurse, social worker, or addictions spe cialist. Often, however, the practitioner will assess patients.

Goals of the Assessment Interview
The primary goal of the assessment inter view is to develop a clear understanding of the patient's current drinking pattern and its associated risks. The interviewer should ascertain the patient's typical and maximum daily alcohol consumption, any past history of heavy drinking, and whether the patient drinks before potential ly dangerous activities (e.g., driving and boating). The interviewer also should identify coexisting medical and psychiatric problems complicated by alcohol con sumption (e.g., hypertension and depres sion) and medications that interact with alcohol (e.g., the anticonvulsant phenytoin).
Another goal of the interview is to identify and evaluate the severity of alcoholrelated problems. Although there is no generally accepted definition of problem drinking, the criteria for alcohol abuse and alcohol dependence in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association 1994) (see this page) are a useful guide. The interviewer also should evaluate the severity of withdrawal symptoms, if present, and consider managing them medically.
In addition, the practitioner should use the interview to understand the patient's perception of his or her drinking. Does the patient feel that he or she drinks too much? If so, why? Is the patient interested in drinking less? Has the patient ever tried to change his or her drinking habits? Fu ture interventions can then reflect each patient's readiness to change.
The final goal of the interview is to begin motivating problem drinkers to change their drinking habits (see brief interventions below).

Suggested Approaches to the Assessment Interview
Several useful approaches have been described for assessing primary care patients with potential alcohol problems. One tactic is for the practitioner to begin with a discussion of the patient's general lifestyle and stresses, followed by asking this question: "Where does your use of alcohol fit in?" (Rollnick et al. 1992). A similar approach is to ask the same ques tion when discussing a specific health problem that a patient is having (Rollnick et al. 1992).
Patients who screen positive on a questionnaire such as the CAGE can be asked for clarification. The interviewer can say: "You indicated that you once felt you should cut down on your drink ing. Can you tell me more about that?" (Bradley 1992).
Individual questions from screens such as the AUDIT or the TWEAK also may be helpful as part of an assessment interview.
Research on the validity of selfreported alcohol consumption suggests that the most valid information will be obtained when the interviewer and interviewee have good rapport and when the informa tion obtained is confidential (Babor et al. 1991). In addition, defining what is meant by "a drink" (i.e., one glass of wine, one bottle of beer, or the equivalent of one shot of liquor); asking explicitly about each type of beverage consumed on a specific recent day; and reminding the patient to think of alcohol consumed between, as well as with, meals may increase the validity of selfreported alco hol consumption (NIAAA 1993b). Given its importance and multiple dimensions, the assessment interview may require several visits. . These collectively can be referred to as "alcohol disorders." According to DSM-IV, substance abuse criteria are as follows: A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12month period: (1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substancerelated absences, suspensions, or expulsions from school; neglect of children or household) (2) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) (3) Recurrent substancerelated legal problems (e.g., arrests for substancerelated disorderly conduct) (4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights).
The symptoms have never met the criteria for substance dependence for this class of substance (pp. 182-183).
The criteria for substance dependence from DSM-IV are as follows: A maladaptive pattern of substance use, leading to a clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12month period: (1) Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of the substance to achieve the intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of the substance.
(2) Withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for the substance (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
(3) The substance is often taken in larger amounts or over a longer period than intended.
(4) There is a persistent desire or unsuccessful efforts to cut down or control substance use.
(5) A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chainsmoking), or recover from its effects.
(6) Important social, occupational, or recreational activities are given up or reduced because of substance use.
(7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psy chological problem that is likely to have been caused or exacerbated by the substance (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption) (p. 181).
Alcohol problems and problem drinking: Refer to the entire spectrum of alcoholrelated problems, including those problems that do not meet DSM-IV criteria (Institute of Medicine 1990).
Hazardous drinking: Indicates patterns of alcohol consumption that place people at increased risk but have not yet resulted in problems (Saunders et. al. 1993a).
Hazardous drinking may result from the amount of alcohol consumed daily, drinking to intoxication intermittently, and/or drinking in certain settings, such as before driving, that place people at risk.

THREE LEVELS OF PREVENTION OF ALCOHOL PROBLEMS IN PRIMARY CARE SETTINGS
Primary care practitioners must fulfill several roles in managing the spectrum of alcoholrelated problems. These roles can be thought of as three levels of prevention-primary, secondary, and tertiary (Institute of Medicine 1990), which is an approach used in the man agement of other chronic diseases. The goal of each level of prevention is the same: to prevent future adverse conse quences that result from drinking. The target populations, however, differ. Tertiary prevention is directed at pa tients with established alcohol abuse or dependence. Secondary prevention is directed at patients with mild alcohol problems or hazardous drinking pat terns that do not meet diagnostic crite ria for alcohol abuse and dependence. Primary prevention targets all patients, regardless of their drinking habits.

TERTIARY PREVENTION
Tertiary prevention of alcohol problems traditionally has been emphasized in U.S. medical education (Lewis et al. 1987). This level of prevention requires practi tioners to identify patients with alcohol abuse and dependence and intervene by referring these patients to alcoholism treatment programs to prevent additional problems, such as trauma and cirrhosis.

Brief Interventions for Patients With Hazardous Drinking
If the assessment interview reveals that a patient drinks in a hazardous manner, the primary care practitioner, as well as nurses and other health care personnel, can use brief interventions to encourage a change in drinking habits (Bien et al. 1993). Offering a patient specific, non judgmental feedback linking alcohol consumption and health can lead to change (Bien et al. 1993). Such feedback can include evidence of harm as a result of drinking (e.g., serum GGT indicating liver damage) (Kristenson et al. 1983) or information regarding potential harm (e.g., risk to the fetus from maternal drinking) ). Explicitly advising a patient to decrease consump tion or abstain, in an empathetic and nonconfrontational manner, also can contribute to change (Bien et al. 1993;Walsh et al. 1992). A practitioner's optimism is another factor that can contribute to a patient's motivation to change (Bien et al. 1993). Because motivation can waiver, patients deciding to change should be counseled to expect fluctuations in their resolve. All patients should be encouraged to follow up with the primary care practi tioner whether or not they decrease their alcohol consumption.

Choosing a Goal
Although many experts in the United States believe that abstinence is the only acceptable goal for patients with alcohol problems, moderate drinking is an ac cepted treatment goal in other countries (IOM 1990).

Moderate Drinking in Patients With
Problems. Patients with less severe de pendence and those who believe they can drink moderately appear to be most suc cessful at moderate drinking (Miller 1986;Rosenberg 1993). Studies of patients without severe dependence who were treated in programs specifically designed to teach them to drink in a controlled manner, report between 60 and 80 percent of these patients drinking without prob lems 1 to 2 years later (Miller 1986). Up to 5 to 20 percent of problem drinkers treated in abstinenceoriented programs have been reported to be drinking without problems at followup (Miller 1986).

When Is Moderate Drinking an
Appropriate Goal? Moderate drinking may be an acceptable goal for two groups of primary care patients with alcohol problems. First, patients with relatively mild alcohol problems, which do not meet criteria for alcohol dependence, may wish to try moderate drinking. Offering such patients a choice between abstinence and moderate drinking may motivate them to change their drinking (Miller 1985;SanchezCraig and Lei 1986).
Second, moderate drinking is an ap propriate goal for primary care patients with alcohol dependence who recognize they drink too much but are unwilling to abstain. At a minimum, helping these patients lower their alcohol consumption might decrease alcoholrelated morbidity.
Several studies of brief interventions aimed at moderate drinking have included significant numbers of patients with alcohol problems. Eighteen percent of patients studied by Wallace and colleagues (1987) screened positive on the CAGE or had a selfassessed drinking problem. Of patients with elevated GGT studied by Kristenson and colleagues (1981), 59 percent had tolerance, 30 percent had withdrawal symptoms, and 20 percent reported morning drinking. These studies demonstrated significant decreases in measures of morbidity, such as GGT, sick days, and hospital days, in men given moderate drinking interventions (Wallace et al. 1987;Kristenson et al. 1981).
Patients who try moderate drinking but are unable to control their consumption may subsequently become more accepting of abstinence as a treatment goal . However, recurrent problem drinking is common among patients treated for alcohol abuse and dependence, regardless of whether the treatment goal is abstinence or moderate drinking (Rosenberg 1993).

Referral
No single alcoholism treatment program has proved effective for all patients with alcohol problems, based on controlled clinical trials (IOM 1990). Nevertheless, most experts agree that all alcohol dependent individuals should be referred to specialized alcoholism treatment pro grams or selfhelp groups (e.g., Alcoholics Anonymous or Rational Recovery).
Most treatment programs in this coun try are abstinence oriented, with a strong emphasis on group therapy. They vary from intensive, inpatient programs to weekly outpatient meetings. Studies are under way to match subgroups of patients to appropriate treatment programs (Project MATCH Research Group and NIAAA 1993); but, at present, the choice of treatment program often must be guid ed by availability, patient preferences, insurance coverage, and cost. Whenever possible, primary care practitioners should identify a colleague (e.g., alco holism treatment specialist, social worker, or counselor) who is familiar with the entire range of local alcoholism treatment options to assist with referrals.

Brief Interventions and Counseling To Increase Successful Referrals
Several interventions provided in the primary care setting can improve the completion rate of referrals for alcohol problems (Bien et al. 1993). Chafetz (1968) studied emergency department patients with alcohol dependence and found that more than 65 percent of pa tients who received brief empathetic counseling and assistance in obtaining social services followed through with referrals. In contrast, only 5 to 6 percent of patients who did not receive such attention followed through.
Once a patient is referred to a treat ment program or selfhelp group, inter ventions such as letters, telephone calls, and followup appointments from primary care practitioners may help motivate patients to remain in treatment (Bien et al. 1993).

Counseling Patients Interested in
Moderate Drinking. Although some selfhelp groups and alcoholism treatment programs concentrate on moderate drink ing (e.g., Moderation Management and DrinkWise), most programs emphasize abstinence. Therefore, patients with alco hol problems who are interested in mod erate drinking may not find a local treatment program that supports their goal. For these patients, primary care counseling also may be helpful.
To begin, the practitioner (or a clinic counselor) and the patient should identify a specific drinking goal (Bien et al. 1993). The practitioner also can make sugges tions that will help the patient achieve the goal of moderate drinking (McIntosh and SanchezCraig 1984). A combination of selfmonitoring (e.g., keeping a daily drinking diary) and other techniques that reduce alcoholic intake (e.g., interspersing nonalcoholic beverages, diluting drinks, and slowing the rate of drinking) can facilitate this goal (Alden 1988). Some experts recommend 3 weeks of abstinence before moderate drinking is attempted. Such a period of abstinence might decrease tolerance and increase the patients' confidence that they can control their drinking (SanchezCraig and Lei 1986).

Motivating Patients Not Interested in
Change. If a problem drinker is not inter ested in changing the way he or she drinks and is not willing to accept refer ral, the practitioner should try to help motivate that patient to stop drinking in a harmful manner.
Limited research has been published on motivating primary care patients to change their drinking habits, but studies in treatment settings (Miller 1985), com bined with evidence from brief interven tion trials (Bien et al. 1993), suggest several ways to bring about change in primary care patients with alcohol abuse and dependence (Rollnick et al. 1992). Some patients may even decrease con sumption in response to assessment, attempted referral, and followup alone (Elvy et al. 1988). Others will respond to the brief interventions directed at chang ing their drinking habits, described above.
For patients who recognize that they have a drinking problem but are not ready to change, practitioners may help stimu late change by exploring the patients' ambivalence about drinking. Practitioners might ask such patients to describe what they like and dislike about drinking, thereby helping them articulate for them selves "their reasons for concern and the arguments for change" (Rollnick et al. 1992, p. 28).

Patient Followup
Whichever approach is chosen for pa tients with hazardous drinking or alcohol problems-referral, brief intervention, or both-followup with the primary care practitioner likely will contribute to change (Bien et al. 1993).
For patients who are not ready to con sider change at the time of the initial as sessment, followup discussions after a period of selfassessment may help motivate patients to change. For patients who wish to change the way they drink, followup appointments allow the practi tioner to monitor their progress and pro vide feedback. Reviewing changes in selfreported alcohol consumption, blood pressure, and laboratory tests such as the GGT may provide positive feedback and contribute to change (Bien et al. 1993). The practitioner can be an important source of motivation and support for patients when hazardous or problem drinking recurs. Primary care followup of patients with alcohol problems also can include prescription of medications to assist with abstinence or withdrawal (Chick et al. 1992;Hayashida et al. 1989).

IMPROVING PREVENTION OF ALCOHOL PROBLEMS
As the gatekeeper in today's health care environment, the primary care practitioner has a great responsibility for detecting and treating or referring patients with alcohol problems. To better recognize and evaluate patients who need help, practi tioners must improve the care provided in the primary care setting.

Prevention and Management of Alcohol Problems: Current Shortcomings
Despite the availability of useful screen ing tests for alcohol problems, patients with hazardous drinking patterns and alcohol problems often are not identified (Buchsbaum et al. 1992;Duggan et al. 1991;Leckman et al. 1984). Patients with inactive or mild alcohol problems are identified less often than patients with active problems or dependence. For ex ample, internists are more likely to note the existence of alcohol problems in patients who have gastrointestinal com plaints or have a previous diagnosis of alcohol abuse (Buchsbaum et al. 1992). In addition, women with alcohol problems are identified less often than their male counterparts (Buchsbaum et al. 1992).
Even when primary care patients with hazardous drinking patterns or alcohol problems are identified by screening, they may not receive appropriate care. Geller and colleagues (1989) reported that fewer than half of physicians in training felt a great responsibility to refer patients with alcohol problems; only 7 percent felt a great responsibility for followup with such patients. Although 93 percent of internists and family practitioners report counseling patients about alcohol use (Wells et al. 1984), this may overestimate alcohol counseling. Patient reports sug gest that physicians frequently do not address alcohol use with their patients (Schorling et al. 1994). In addition, physi cians appear most likely to counsel pa tients who have severe, active alcohol problems (Buchsbaum et al. 1993).

Suggestions for Changes in Primary Care Practice
Certain methods for administering tests will improve the identification and man agement of patients with alcohol problems. Embedding screens in selfadministered health questionnaires identifies a greater proportion of primary care patients with alcohol problems than if screening is left to physicians (Wallace et al. 1987). Response rates for such questionnaires appear to be better when the question naires are mailed to the patients, rather than administered by office receptionists (Kemper 1992;Wallace et al. 1987). Ado lescents with alcohol abuse and depend ence may be identified more often if interactive computer programs are used for screening (Paperny et al. 1990).
Programs in which nurses screen patients also may improve the identifica tion, referral, and followup of patients with alcohol abuse and dependence. A study in which nurses screened general medical outpatients and referred them directly to an addictions counselor in creased the rate of referral from 2 to 10 percent (Goldberg et al. 1991).
Similarly, when results from a diag nostic interview were provided to primary care physicians with explicit recommen dations for counseling, the rate of coun seling by physicians increased from 33 to 50 percent. Such screening and prompting especially increased physician counseling of patients least likely to be counseled: women and nondependent problem drinkers (Buchsbaum et al. 1993).

Augmenting Education and Training
Educational programs should help pri mary care practitioners develop the atti tudes and clinical skills needed to assess and manage patients with the entire spec trum of alcohol problems. At a minimum, more curricular time should be devoted to alcoholrelated issues in medical schools, residency training programs, and continu ing medical education courses (Adger et al. 1990).
Physicians in training have to develop a sense of responsibility, and optimism, toward their patients' alcohol problems and confidence in their clinical skills related to caring for patients with these problems (Geller et al. 1989). Practition ers will acquire these qualities only if they have adequate clinical exposure to pa tients with alcohol problems (Bradley and Larson 1994).
In addition, practitioners likely will need experiencebased learning, such as that learned from roleplaying and super vised clinical practice, to develop the skills required for assessing and intervening with patients who drink too much (Adger et al. 1990;Warburg et al. 1987). Although knowledge per se does not appear to im prove physician management of alcohol problems (Geller et al. 1989), secondary prevention and brief interventions have been relatively neglected in the U.S. medi cal literature (Bradley et al. in press). There fore, practitioners may need increased didactic teaching about these topics.

Focusing Future Research
Improving the prevention of alcohol prob lems in primary care settings also will require additional research. Several specif ic issues merit investigation.
Identifying the optimal screen for hazardous drinking and mild alcohol prob lems and evaluating which components of brief interventions are most effective in primary care settings are two significant issues. Studying how to distinguish pa tients who will respond to brief interven tions by primary care practitioners from patients who will benefit from referral to treatment programs is another issue. Also, research must be conducted to deter mine whether primary prevention can reduce alcohol problems. Finally, medical educators must learn how best to prepare primary care practitioners for their diverse roles regarding the prevention of alcohol problems. ■